[Show abstract][Hide abstract] ABSTRACT: Gastrointestinal tract duplications (ATD) are rare malformations that occur with an incidence of 1 in 4000-5000 live births, with heterogeneous clinical pictures in relation to the different location and size. The purpose of this study was to analyze the role of minimally invasive surgery in the management of ATDs, through a critical analysys of 15 years of experience of the Department of Paediatric Surgery, University of Bologna.
The medical records of 22 children diagnosed with ATDs were retrospectively reviewed (January 1995-August 2010). The study analyses: clinical presentation, preoperative diagnosis, site, anatomic type, treatment, and outcome.
Children were 16 males and 6 females, with age ranged from 1 day to 10 years. 20 ATDs (91%) were cystic type, while 2 cases (9%) were tubular one. During the first period of our experience, 10 (45.5%) cases were approached with an open surgery. Then subsequent 8 (36.4%) cases were treated with a diagnostic laparoscopy. This approach permitted also to perform a minilaparotomy, close to the site of the malformation, with a short length of the scar. In 2 cases (9%), we realized an ileal resection with end-to-end anastomosis with a trans-umbilical video-assisted procedure. In 2 cases (9%), we performed a complete removal of the lesions, after complete ligation of the vascular pedicle through a laparoscopic approach. 10 cases (45.5%) were located in the ileum, 6 cases (27.3%) were esophageal duplication, 3 cases (13.6%) were gastric duplications, 2 cases (9%) were located in the colon-rectum. The postoperative course was uneventful in all the cases.
this study shows how, in the management of intestinal duplications, a mininvasive approach, is increasingly taking the field, along with increasing the "learning curve" with laparoscopy. In experienced hands, the laparoscopic approach allows an accurate definition of the exact site of duplication and a miniinvasive treatment with similar principles of open techniques.
La Pediatria medica e chirurgica: Medical and surgical pediatrics 10/2012; 34(5):217-22. DOI:10.4081/pmc.2012.57
[Show abstract][Hide abstract] ABSTRACT: Although it is virtually impossible to formulate a scheme that can satisfactorily collect all different types of vaginal malformations, a simple classification would be of a considerable value and would permit logical operative decisions. Many classifications of anomalies of uterus and vagina have been proposed: we find them unsatisfactory and confusing, being either too simple or too complex. We propose a new classification, focused only on vagina and based on embryological, anatomical, clinical and surgical criteria.
In over 30 years, 167 females with vaginal malformations have been observed in our department. Intersex cases were excluded. The encountered anomalies have been divided into six types and ten subtypes: type I vaginal agenesis (IA associated with uterine agenesis/17 Pts, IB isolated/1 Pt); type II vaginal atresia (IIA proximal/1 Pt, IIB distal/4 Pts); type III vaginal atresia with urethrovaginal fistula-urogenital sinus (IIIA proximal fistula-high sinus/42 Pts, IIIB distal fistula-low sinus/55 Pts); type IV vaginal atresia with transverse septum (IVA transverse septum/6 Pts, IVB imperforate hymen/17 Pts); type V disorders of müllerian ducts fusion (VA vaginal duplication/4 Pts, VB longitudinal septum/4 Pts); type VI cloaca/16 Pts. Of each type and subgroup of malformation the appropriate surgical correction is reported. Types of malformation and surgical treatment are analysed: IA vaginal reconstruction using a sigmoid conduit, IB vaginal reconstruction using a sigmoid conduit, atresic cervical resection and uterus-new vagina anastomosis according to Schmid; II perineal vaginal pull-through; IIIA anterior sagittal transanorectal vaginal pull-through, IIIB perineal flap vaginoplasty; IVA excision with abdominovaginal approach, IVB hymen incision; VA tubularization, VB septectomy via perineal approach; VI posterior sagittal anorectal-vaginal-urethroplasty.
Most of the patients had good aesthetic and functional results. Type III showed relatively more complications: four redo operations (IIIA), four revisions of the vaginoplasty (IIIB). One patient is still waiting for definitive surgical correction.
An early diagnosis is desirable to correct adequately vaginal malformations, which becomes mostly evident around puberty. The better timing for surgery is early age, to obtain better results and to avoid many of the psychological problems that arise at a later age.
Pediatric Surgery International 07/2012; 28(8):797-803. DOI:10.1007/s00383-012-3121-7 · 1.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic nephrectomy in children has gradually become a reasonable alternative to open nephrectomy and, besides, a retroperitoneal approach seems more logical than transperitoneal approach to perform nephroureterectomy for benign disease, as in open surgery. To further reduce the access-related complications, we propose a retroperitoneal one trocar-assisted nephrectomy (OTAN). We report our experience with minimally invasive OTAN for the treatment of benign renal disease.
A total of 27 OTANs were performed at our institution between 2003 and 2009. The median patient age was 7.6 (range, 2-32 months). Indications for unilateral nephrectomy were multicystic dysplastic kidney (MCDK) in 23 cases (85.2%), dysplastic kidney in 3 cases (11.1%), and reflux nephropathy in 1 case (3.7%).
The median operative time from the initial incision to skin closure was 60 min. Perioperative transfusion was not required in any cases. No major perioperative complications developed. Conversion to open surgery was necessary in four cases (14.8%): in three cases for a small working space arising from a peritoneal perforation, and in one case for a difficult visualization of the parenchyma (renal fusion not detected by preoperative ultrasound evaluation). Most patients were allowed oral intake on postoperative day 1. The median hospital stay was 2 (range, 2-3) days; the cosmetic results were excellent. Convalescence was uneventful in all patients.
Although the indications for a nephrectomy in case of benign disease remain limited, when a little child has small, poorly functioning kidneys that must be removed, a one trocar-assisted approach for nephrectomy is usefully a safe and effective treatment choice. The procedure can be easily performed through a small incision with minimal morbidity, comparable operative time, and excellent cosmesis without excessive postoperative pain issues, allowing early discharge home.
[Show abstract][Hide abstract] ABSTRACT: The absence of vagina is rare in the pediatric population. It can occur as a result of congenital malformations such as an aplasia of mullerian ducts (46,XX Mayer-Rokitansky-Küster-Hauser syndrome) or a complete androgen insensitivity syndrome (46,XY testicular feminizing syndrome). Intersex patients, who underwent reassessment of a female sex, need a genital reconstruction toward a feminine phenotype. Patients with congenital adrenogenital syndrome with high urogenital sinus could have a severe hypoplastic vagina. In all these cases, a vaginal replacement is required. We reviewed our experience of vaginal replacement using a sigmoid conduit.
Journal of Pediatric Surgery 10/2010; 45(10):2087-91. DOI:10.1016/j.jpedsurg.2010.05.016 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this paper was to report the management of a very rare malformative association of Left Pulmonary Artery (LPA) sling and Tracheal Lobe which is not still reported in scientific literature.
The Authors describe the clinical case of a 6 years old girl that was admitted for chronic respiratory symptoms associated with recurrent upper respiratory infections. The CT-scan with virtual bronchoscopy showed an ectopic bronchus arising from the right side of the upper third of the trachea and ending in an accessory pulmonary lobe, covered by normal pleura, located in the upper mediastinum. The tracheo-broncoscopy showed a stenotic tracheal lumen with complete cartilaginous ring with an evident vascular pulsation in the middle of stenotic tract. An angio-CT confirmed the vascular anomalies with the LPA which passes between the lower trachea and the accessory tracheal bronchus and the coexistence of a persistent left superior vena cava. The surgical approach, after the thoracoscopic exploration, was a double procedure through a median sternotomy with cardiopulmonary bypass has permitted to excise completely the tracheal lobe and to reimplant the left pulmonary artery into the main pulmonary artery.
No more upper respiratory symptoms or pulmonary infections have been observed during the clinical and instrumental follow up.
Current controversy in the management of Pulmonary Artery sling include surgical approach (median sternotomy versus left thoracotomy), use or non-use of cardiopulmonary bypass, and reimplantation versus translocation with distal tracheal resection. In our experience LPA reimplantation and tracheal lobe resection have been made easily and safely by the same sternotomy utilized for the cardio-pulmonary by-pass.
La Pediatria medica e chirurgica: Medical and surgical pediatrics 31(6):252-7.